| NPI | 1861679151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6583) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA20417) |
| Enumeration Date | 2008-01-29 |
| Last Update Date | 2020-09-10 |